Neuro part 2 (1)

Sleep Disorders Overview

• Sleep apnea can lead to serious conditions like heart failure if left untreated.

• Narcolepsy is characterized by overwhelming daytime drowsiness and sudden sleep episodes.

• Chronic sleep deprivation can weaken the body’s defenses, leading to infections.

Insomnia

• Defined as persistent difficulty in sleeping.

• Important to assess the underlying cause (medical, psychiatric, substance abuse, or primary sleep disorder).

• Questions to ask patients:

  • Type of work and bedtime routines.

  • Presence of bed partners (pets or people disrupting sleep).

  • Use of over-the-counter drugs or stimulants.

  • Frequency of nighttime awakenings and actions taken when unable to sleep.

  • Habit of taking daytime naps.

Identifying Sleep Problems

• Determine specific issues: difficulty falling asleep vs. staying asleep.

• Use this information to decide on non-pharmacologic interventions or pharmacotherapy.

• Treatment goals vary per individual; some function well on 7 hours, others need 10.

• Consider side effects of medications like residual drowsiness.

Classes of Drugs for Insomnia

• Orexin Antagonists: Block excitatory neuropeptides associated with wakefulness, aiding in sleep.

• Benzodiazepines and Non-benzodiazepines: Enhance GABA activity to promote relaxation and sleep.

  • Important medications include Zolpidem (Ambien), Triazolam (Halcyon).

• Melatonin: A naturally occurring hormone that regulates the sleep-wake cycle. It is lipid-soluble and has agonistic activity at melatonin receptors.

  • More potent prescription melatonin is available compared to over-the-counter forms.

Sleep Onset Insomnia Treatments

• Identify key agents for sleep onset difficulty:

  • Zolpidem (Ambien): Non-benzodiazepine; generally not habit-forming but can lead to tolerance.

  • Ramelteon: Melatonin receptor agonist with no habit-forming properties.

Sleep Maintenance Insomnia Treatments

• Orexin Receptor Antagonists: Newer agents effective for insomnia maintenance.

• Lunesta: Commonly prescribed; helps maintain sleep but may cause morning grogginess.

• Benzodiazepines: Third-line agents for maintenance; can lead to tolerance and dependence.

Additional Considerations

• Avoid long-term use of antihistamines for sleep due to rebound effects.

• Trazodone can be used but is not considered a first line treatment for insomnia.

Restless Legs Syndrome (RLS)

• Also known as Willis-Ekbom disease; characterized by an overwhelming urge to move the legs.

• Linked to low iron levels and dopaminergic disturbances.

• Treatment options include iron therapy and dopaminergic agents.

Narcolepsy

• Narcolepsy is associated with loss of orexin, leading to excessive daytime sleepiness.

• Complications include cataplexy (sudden muscle weakness).

• Treatment options include Modafinil (dopamine reuptake inhibitor) and Sodium Oxybate (used for cataplexy).

Neurodegenerative Disorders

Alzheimer’s Disease

• Characterized by neurofibrillary tangles and amyloid plaques leading to dementia.

• Drug therapy focuses on symptom management:

  • Cholinesterase inhibitors (e.g., Aricept, Exelon) increase acetylcholine to enhance cognition.

  • Memantine: NMDA receptor antagonist for neuroprotection.

  • Disease-modifying agents: Lecanumab and Gonaneumab aim to slow disease progression but carry risks such as brain bleeds.

Parkinson’s Disease

• Characterized by degeneration of dopaminergic neurons and the formation of Lewy bodies.

• Treatment strategies include:

  • MAO-B inhibitors: First-line therapy for enhancing dopamine levels.

  • Levodopa combined with carbidopa for symptom management, especially in older patients.

  • Dopamine agonists and anticholinergics may be considered.

  • Monitor patient response using the Movement Disorder Society Unified Parkinson’s Disease Rating Scale to guide therapy decisions.

Conclusion

• Emphasize the importance of a comprehensive approach to treatment, including lifestyle changes, safety measures, and patient education about their condition and medication.